HomeMy WebLinkAbout042-1085-80-000 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON WI 53707 RECONNEC
NE%,NW4,S 31,T29N-RI8W ]CONVENTIONAL ALTERNATIVE Stete Pie,I,D.Number:
(If assigned
Town of WaAAen ❑Holding Tank ❑In-Ground Pressure ❑Mound
I-94 9 70th S;fteet
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
JoAnn 6 Viotet GuLken Route 1, Box 172, Robeh6, W1 54023
BENCH MARK(Permanent reference pomt)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV., ]CSTREF.PT.ELEV..
Name of Plumber. /MPRSW No.: County: Sanitary Permit Number:
Robert U&Iitich MP 3307 St. CAoix 112733
SEPTIC TANK/HOLDING TANK:
CAPACITY TANK INLET ELEV.: TANK OUTLET ELE V.. WARNING LAB L LOCKING COVER
MANUFACTURER ILIQUID CA pq OVIDED. Pq OVIDED
❑YES ❑NO ❑YES ONO
BEDDING: VENT DIA. VENT MATE, HIGH WATER NUMBER ROAD: PROPERTY WELL BUILDING.(VENT TO FRESH
ALARM, - LINE. (AIR INLET
FEET FR
❑YES ❑NO ❑YES ONO N
DOSIN G CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY:=PUMPISIPHON MANUFACTURER AC TIIRER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ❑NO ❑YES ❑NO OYES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
LINE AIR INLET
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) DYES ❑NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL A"°MARKwG
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH'. LENGTH NO.OF DISTR.PIPE SPACING. COVER INSIUE DIA »PITS LIQUID
BED/TRENCH TRENCHES. MATERIAL: PIT DEPTH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH IDISTR PIPE DISTR.PIPE DISTR.PIPE MATERIAL. NO DISTR NUMBER OF PROPERTY WELL BUILDING VENT TO FHESH
BELOW PIPES ABOVE COVER. ELEV INLET ELEV.END. PIPES FEET FROM LINE AIR INLET
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
OYES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS =011SIHVAON❑YES ❑NO ONO
D TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED MULCHED
ENTER EDGES.
❑YES ❑NO ❑YES ❑NO 1:1 YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR UIST R.PIPE DISTRIBUTION PIPE MATERIAL&MAHKIN(,
ELEV.' ELEV.. DIA.. ELEV.. PIPE$ DIA:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
1:1 YES ❑NO DYES 1:1 NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS'. NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE
[1)YES ❑NO 1:1 YES ❑NO NEAREST
i
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATURE. TITLE
DILHR SBD 6710(R.01/82)
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SANITARY PERMIT APPLICATION COUNTY
� DILHFR In accord with ILHR 83.05,Wis.Adm.Code 5"1.
STATE SAN ITAFU PERMIT#k
7
-Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in size. /(/
-See reverse side for instructions for completing this application.
PETITION
1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO
P OPERTY OWNER �f n� PROPERTY L�CAJION
, V/()� /{(M/a, S 31 T2 , N, R �b' E(orJ`Yy/
R RTY OWNER'S MAILING ADDRESS LOT MBER BLOCK UMB SUBDIVI E _qON NAM
v 190)( 10?-' PAO
Y,STE ZISP.c�o� PHONE NUMBER CITY NEAREST ROAD,
�i 9 L 44114 46 VILLAGE: ��-
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family 2,— OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a. ❑ New b. ❑ Replacement c. ❑ Replacement of d.X Reconnection of e.❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2 A Sanitary Permit was previously issued. Permit## Date Issued
iAn Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in##1 and only one in##2) `X���,��f Xf l IT — �6�J�
1. a.9Conventional b. El Alternative c. ❑ Experimental 5""x70 -,
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. Mound f. El IGP [�
In-Fill Tank 1k., /lE� V^�/,-d
V. ABSORPTION SYSTEM INFORMATION: (Check one) EX f S T//U 6— 7- /,s,f '7 X6-
1. a. ❑ Seepage Bed b. See a e Trench c. El Seepage Pit (-Q
2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): f ROPt7M(Square Feet):
3.30 �— 330 74/, 72— Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total ##of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks I Tanks strutted
Septic Tank or Holding Tank ❑ ❑
am er
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name(Print): Plumber's Signat re:(No Stamps) MP/MPRSW No.: Business Phone Number:
ko 6exj a11iX feA/ 330 �p�o
Plumber's Address(Street,City,Stete,Zip Co e): Name of Designer:
6 97 S - 0�3a.•� 4:)
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name HOMESITE SEPTIC PLUMBING CST
655 O'NEIL RD.,HUDSON,WIS.54016 L�
CST's ADDRESS(Street,City,State,Zip Code) Phone Number: F6
WIS,MA>TIA PLUM89A LIC,NO.3307 M.P.R.S,
A tAtusiatimi Liel, n Q= 3 B212
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate I uing Agent Signaat/urree(No mps)
19 Approved
F-1 Given Initial �/ 6 charge k Fee �' �� 1 V ( .
Adverse Determination
X. COMMENTS/REASONS FOR DISAPPROVAL:
-0 laP, V\O n W
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
,
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation;
5. Private sewage systems must be properly maintained,. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
111. Purpose of application: Check only one in ##1. Complete##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn,to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into,law.'This legislation is more
commonly known as the groundwater protection law.This-change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Groundtr—1
included the creation of surcharges (fees) for a number of regulated practices which Wisco 1161
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried T$< &uC$'. a
is used in your building is returned to the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumper.
0
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended for resale by
owner/contractor, (spec house), then a second form should be retained and
completed when the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property 4,,, -I,.e
Location of property b c 1/9 �� 1/4, Section J , T_:�F_N-RIFW
Township 1V1Z""- '
Mailing address �7 '� 0 ��' ��} S� `
Address of site
Subdivision name
Lot number
Previous owner of property �� A0 Atiti--sL,
Total size of parcel 2,3 - 5 �C s
Date parcel was created 18 410 R
Are all corners and lot lines identifiable? x Yes No
Is this property being developed for resale (spec house)? Yes _ No
Volume 3 )-5- and Page Number Z3 as recorded with the Register of Deeds.
-------------------------------------------------------------------------------
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and
the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if
available, would bq helpful so as to avoid delays of the reviewing process. If
the deed description references to a Certified Survey Map, the Certified Survey
Map shall also be required.
-------------------------------------------------------------------------------
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in
this information form, by virtue of a warrant deed recorded in the Office of
the County Register of Deeds as Document No. J2--) - ; and that I (We)
presently own the proposed site for the sewage disposal' system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the Cou y Register of Deeds, as Document Np/�
71ai'tre of Owner Signature of Co Owner (If Applicable)
-7- '' - ;?" (::ZT
Date of Signature Date of Signature
S 327"1 ON* •
'T. $own •.I angg: as"lr
itth him wilt.
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tllr Visist A6 -Md Statistics,
MAD ietimt rw�` riMS
btasls oadlld tirNasse ttRellrar acs a anew,
WfT3x=CM Tim 1M McMarr,r eosslMw/lew of the p wamft to be facie and*o
V
wewMsMr and aloe msls by the pwebaew M be MferMfi. a bereman" act fwtb.
iwtlbp sells and alas M ewmw sand the PtiabMw.teas the prat attd fWl perftas M111gM•TO
seas � the Pwahacoe of the sevenwals atad e/astsan nd*M eawtrsnt ti M by rte s`a
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Ptaabeess pin, so tonewim described Now eases,M st z
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That certain parcel of land or tract of real Ntatt 10 the xerthast of the xorthsNt Q Of / cticn pl Township xDrh, Raoe t g� d
I
want, TWO ed
Warren, nNw fully described as foILILc : !
The Part of the said Northeast Quarter of North e t Qwss�er }
lying North of Raft"tate nish"y K, the 0,11110111
--Wqww".,/arOei containing 28.84 aerN, •nimi
yk4
t 101A.r wMA all belw r l
hap. ht/eovemerrta,/harms.ad eppwlaaase...new of bareaflar meow Mateo&,"don"an sasses
dens ad Or'adaws.attached mirrors.ficttres, shedes. amebad now combs bet wow' fiwswe.on Mob serf ftu whkA emu be s part of the...!estcte. _ �.'
D
The P*Cboew, in coaidwstla of the covessab and alos sswe here so moo by tae raadw, so*" to pwebaa � alieod
described promises, and to pay thnofar to the Vender st
at.arm N_ and wayJ
is teaser fed s a� M*9 attctttlas bwoaf.the sealbt wbwoo M baroby seb P and any bttk*w
of=�d - .loll"b"with intareat on each pertinent thtaoof as absll ratceb Ram tiara to lisle n psld.o rli M1e �
—per Cant per annam. until paid in fully. ►a fdlawt Safi prUr+pa!cad iwlarea- sisal 6,payable
MNapmsMs of not loss than s`=23Q
ago___19 'rte--__ADZ—
day
at .baSfaslas..lMa Lt s
prevNad the saire pweAaae Masep tali lsleiest shall M fttry p�If }
eigb�___ -- yeah from tA.e.le hereof. .
e ParchaPurchcsw(WOW aleoa, unless accused by Vesdw.to pay usably payments suttfioient esaswY7 N antieipls thus
ta special taosassamwt,fire cad atas/ed coveratVe premiums and such olAsr insurance prsuainms a Ysader mqr w,sirs,cad
Payments to the Vendor�hereby atNHas Vendor be fly�scar r p�yMo of�h treats. '
purchaser shall have the right, in cage of default
of TNdo:r an a parieil' r °,
land contract between Teador sad senjiman We stork and NYI&, F. atom*,
his wife, to make payments directly to the AtorM and TNdoe &grow. to '
apply those payments to purchaser's obligation sunder this land contmaet,
Said psymewts shell be applied first to interest on the unpaid below@ at the rote berets specified end than to prisel/a1. Ate
&I&*"# may be prepaid without premium w tee upon principal at ay time, and interest Nall be calculated at ap times a the sttpaii
balance on the daily rate basis at 1/360 of the annual rate.
In the event of any pepayauent, this contract shall sot be treated as M default with respect to payment se
then t e of pretcipat, seal interest fend M such case accruing interest from month to most shall be t a tutee as do
than the %moat that said indebtedness would'bsve been had tMe monthly payment• brew made as tint itMf
monthly Payments shall he continued Me the event of credit of May proceeds of uaurace or coademnaties, the eendarrod p #:
being thereafter excluded be►etrots. premina
The Purchaser hereby states that he Is sntisfled with the title a shown by the abstrect-title insurance coatmllmetit atAmille�
him for examination;the Vendor agrees to deliver the abstract-title insurance policy to tht Purchaser when the full puwehw
hereunder shalt have been paid. The Purchaser agrees to pay the cost of later continuations of abstract-title insurance, price
(/)RMI,-Vendor shall furnish the Purchaser thirty days prior to the date of ultimNe elosing. Mad the PurcMsar •tuall ace as 0
sufficient showing of title, either (1)a title Mturanee CewtmilWAMt for a owner's policy of title Mauwace M the cum M
price, the Purchaser to be named as the assured, to be writter by a title Inttrance Coatpay, and tpr• to in h the office's tltit
the condition called for by this agreement, a (2)a merchantable &hstrset n*owirtg the Vendor's 9U M IAN eo the VI Called fur ,&jo
this agreement, If a abstract l•furwlslued,the ParoAaaor shall rotor the Vender,in writing,of any objectioes to title within tea(19, "�
days after receipt of web abstract, and the Ve84er&ball than have •reasonable lime within which t.,reetifythe title ar furnish,a tllls
Policy as abuse described.
The Pwcbcsar Nall be eetltlied to take pasassloc Of aid premiss a dnnri s 1nZa_. estMrF`
ppssssaasiow N N M obtained N tie Va be shall hose•eaasewabie time after &ueA dcle h wA1CA to remeva asy so,,
Tb
PweAaa,shalt M ooitled a ra%acin M poaesala w lasg a M parfarms all earesants and ag osisa to hweln moo/sad •s", part
to be prIN= and an leap►.
LAID Few AL 4111110 fIWSMM!-on" /AR M� if— My1
p i
7KI
»��"� NI'f>IMMs.�aytabs A folfewat
oesit at air to illrar b ' sew ar baeatTMr obsessed W k.trin/ �M�f
1s'4 a11Y Ir+aMeb Isataed for fie at:d s aeW@Wisg due Mywsat themet. "
01 tltiM dtla.acted N e esfsadbd far at best
maply with colwteance prwlsMoa, it any. b Yw
M PNdsr oa istMwbt stay atppbbr, sad di psliciss eeeseisg said premises stall M w1r as/heldlry
�'�`.�~�tbsrSttsarlbes M fh»d easdlfiea sad repair.
tea
� rr� fits�lists• ,
a upNiw to the Lisa of this eowhact, a the rights of the Vsailor In dw
Walk b ssmtU na as not addr WON*to be camoitima /�etibss. F
#�-> It M M t1a/aKt tttiiei abau impsk this value thereof.
0^6M*am sr gesMStame rewow sapaid aMr they become del
ib appresM isles dtrposked.or the insurance p irtgtteat,a in case of failure to keep the
tl sae g Ned, ,b tom the same is good condition and
N sad such defaults. she all hams so paid shell immediately be repaid to the Vendor sad
Part of the pwcbssa price.sad bear interest at the role aforesaid.
y tied bisll M lth/eafforesaid purchase price with the interest and other moneys shm,be lstl� A
attsatlfbd air 41191 led to tMwPtrehsa« at the times and to the manger above specified. be will as ds�aat x
aTr Mbar of bn Mpi llsas sod aacwsh.a good sod sufficient Warranty Deed. in toe simple,of the
awces,except any liens or encumbrances created by the act or 4
of tIt)t a r,
TM P1rehNar hereby covenants and sprees that time shall be deemed to be of the essence of this contract and in cane at
of my principal or interest wbsn the same shall become due.or in the performance of any of the conditions, case
My the Parches"hovels to be hept or performed.and such default shall continue for period of g� V'
�.N IoM eptioa.dselare eke contract at an cad, all rights of the Purchaser under this agreement cancelled, sued the.then till
Ptlreiebsr bsramdsr forfeited.the soma to remain the Vesdor's property,as rental of said otsatlals ' "
�11ara c ub to fW1i1l tlt/s premises and ps ligttidb""
r1 fib Yea/or oa/w tesast; and tlteVendorshdlforthwith and without notice have the rigMof rt.egyr € Y
tgtata Mice to the Pnrohessr, notice Ming hereby expressly waived. the whets amount f
PL_ ll M dstambd b haw became due sad payable; is case such option shall be exercised. the unpaid priao 1 mad .
or have boom psis)by the Vendor as herein authorized witA interest on such dis bilareA ceaetiNa b•suit at law, or by foreclosure otthis contract in the same manner u Iftch whele��s at d bey due N the time who aq anc►dstault
iN Ste boos w din occtared.,and the indebtedness shall embrace,witb said unpaid primeipbi
lnraN Wilk interest as aforesaid '
lls��ee of 19"1 proceedings is aafarceaant of
MY Si a ysss.ahau be added to lieMod, tether abated or got, all expenses. including
'
/rrcipal, become due as'lacurred, and in case of judgment shall be included theurrs Sts.
Ut
•/lfiag tV pendency of any actiaa of fouecl�sure of this contract. the court may a
Isclndisg heoaetead lmm"at,sad may eopawar the racsiver to collect the rents, issues, aged profk safdt
'-t
tltb Msdsscy sf astei actMa, asd—7 srMr abed vasta. Issues. sod profks wbsn so collected,to ' held and applied ss tetltltb ��S'
ir•fir to tkw.divot.
1111 twos,comilkligago
Covenants,wmaMMe she prooisbs hovels shall be binding upon sad inure to the battafk of tin a °i
ps
"Make/wa �evwar pin If not as owner of the propm y the spwee of a�
N Ito aadr is ignmasat hereof. hetssetesd rl&Ip r the subject property and ogees to join is Iles ana0lrtlan at ''
2Melded at em 111ut��dw i :.
1 this._aAd—_. day of
•f=D AND s8AL83) IN PStESENCS Our
Roiar*_B._Ba1yAr
✓._T� 'Y ;� ��. it
Anne Ruth Sa
�� .: Violet � Gerken '
r �
_J - ae V. Gerken * k
AUTIMMCATION
940@tW"Of
�iaatsd this day Of---- —- - 19 - --- ,
N/A'
Title. Member State liar of Wisconsin or Other party J'
Authorized under Sr.. 706.06 viz•
STATE OR WISCONSIN _._—_-_--
;.,. at. Crola_ ...
_ County.
POMOMIly coma before me, this—_
— . 204 -- -. day of June 19 ' t•z='
So aMw samed—Robert-3,So
•inlet �" suer ond Win.- AYGe�rk�sn wyer, his Wife, and .ane Y. - -. -
-
40 so knows to he the 8 ;.�'♦. ? ----
pereon who executed the f
sragerg iMtruarrrt and acknowledg d e same. V ....
"1lSis isMrnaent was drafted by
x1
11rsb B. Gavin, Attu. _ ___-- o •�'•
mod. �ioetan/aiw 8t. ClO�1? `• •i;
Notary Public
tlaia at witnesses is eptiaasl. N .
My Commission(Expires)(a) x.,
4 s sf NwaM siwhg In saw ebMeky alm"be• 'sr pNNb bobw their signatures.
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S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St . Croix County
OWN ER BU YER__�o
IV,,
ROUTE/BOX NUMBER0\ �C "
�`�Z .Fire Number
CITY/STATE eS ZIP
—� �rti .,• ,,
PROPERTY LOCATION : Nrjt, NIA) 14, Section, T N R fi ' .
Town of St . Croix County,, • '�:
Subdivision
Improper use and maintenance of your septic system could result in :M
its premature failure to handle wastes . Proper maintenance con- ? ,
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into "
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St . Croix. County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1 , 1978. St . Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St . Croix County Zoning a
certification form, signed by the owner and by a master plumber,
Journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary) , the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. c
I/WE, the undersigned; have read the above requirements and` agra* N .. 3`
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as set by the Wisconsin Depart- o
ment of Natural Resources . Certification form must be completed
and returned to the St . Croix County Zoning Of Ue within 30 days.
of the three year expiration date.
SIGNED --Lts�t I
•
DATE
St . Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address. �► � '
I
REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
D
' P.O. BOX 7969
.:LATIONS PERCOLATION TESTS (115) MADISON,WI 53707
(H63.09(1) & Chapter 145.045)
�AT1UN: SECTION TOWNSHIP/MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME:
y 1/ -3 If /T.21 N/R 19E (u, u,,j 1, 4,v DAB(——A-O Z " l'�tRCE�.
r -
COUNTY:. OWNER S7BUYER'S NAME: IVIAIUN ADDRESS:
yi o/�t j ��� ,P% !u i So,J .f�� . _/�0 6 t_�P Ti 60/S .
USE `�`� DATES OBSERVATIONS MADE
NO,BEDRMS,: COMMERCIAL DESCRIPTION: PROFILE DESC PTIONS: PERT bCAI N TESTS:
Residence ? New ❑Replace
t �__5�TAW- s,2,r �o,►AJ s s
RATING: S=Site suitable for system U=Site unsuitable for system
r[KISYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(uptional)_ou I DQ S ou I NS ❑u S_[a o S ®u �-0A)wt�r0-vfz, 134-
II Pwa,l.lion Tests are NUT eyuoed DESIGN RATE: .3 j
� p �p S Q'F/ It any portion of the lusted uiva is tit the
urtdei s.1463.09(5)(b),4ndicate: - �ku /200 r1 -foA I Floodplain, indicate Floodplain elevation:
!F/t1Gir'cD PROFILE DESCRIPTIONS
Fr
BORING TOTAL. PTH TO GROUIN DWATER-I ~rS CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE,AND DEPTH
NUMBER DEPTH Mj. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
Q q O ----- 00 /.0 'P.AV. $;d-.h x.0 '144 .5'/1- , 3 0 ' w;x. of �►-
B- / _ O .0 7 S, omiik r z-o0 8,�. SL
B- 2 g. 0 ys79 , > F , �yro�:164). s;" -aV. S;L , i5 '.T�w. s;L , Z0 ,
A u SL C
B 3 9 •. o•y--1' �. 13,j. S, 8• S,•1. , 6?,ae'dv. "f4 ) .(0 7,9713 - C S , S t 3 5 ' 74-Aj CS -
B - •67'D13 N.511- QN. s/ o' MAI.NAP. S'�D.p /0/. 3y ' >/D. 0
B- ,� /o.0 9�-�a' - Rio,p , .,s- .�s;�, .7s'&1.s;� �s' r,,,J SL, .&7 �
B-
PERCOLATION TESTS
TEST DEPTIf WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD I PERIOD _E PER INCH
--
`
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the horn
tontal and vertical elevation reference points and show their location on the plot plan. Show the surlace elevation at all burings and the direction and percent
ul land slupe. Ba/—0.ti o/= /3�v �XC d�4Ti0.�l �l !-� L.t S: 7 ' Re%cam
SYSTEM ELEVATION 0&?;r, ,ptF. nT '-4r 73,
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1, the undersigned, hereby certify that the soil tests reported on this forrn were made by me in accord with the procedures and methods slfner ed n the Wisconsin
Adininistrative Code,and that the datarr,ecorded and the location of the tests are correct to the best of my knowledge and belief.
-WA-WE(PIint): �O q✓`'i1�tr�a lI TESTS WERE COMPLETED ON:
H t M !"l E 4 G' Co. flit y / 3 — b?3
!i()DRESS: i .J, �'y��Q� ��� CERTIFICATION NUMBER: PHONE NUMBER(uptional):
� �y� ✓rS Oj- ytC2-- 'P(o -PLd' "
��V� vr �i�r—c646(f CST SIGNATU+E:
DISTRIBUTION:Original a id one copy to Local Authority,Property Owner and Soil Tester.
UlL 1111 SBD-6395 (H.02/80 OVER —
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